Do I need a scan if I have BPPV?

What is BPPV?

BPPV (Benign Paroxysmal Positional Vertigo) is a common condition, affecting 2.4% ofindividuals at some time in their life. BPPV is a condition of the inner ear where crystals that belong in one area migrate to another area, called the canals, which causes an over stimulation of the nervous system resulting in vertigo (spinning) amongst other symptoms. It’s name means:

  • Benign - not life-threatening

  • Paroxysmal - occurring as brief, sudden spells

  • Positional - triggered by certain head positions or movements

  • Vertigo - A false sense of rotational movement.

Do I need a scan if I have BPPV?

Not usually. Luckily, BPPV is usually straightforward to diagnose and can be done by undertaking special positional changes that cause a very specific response by the nervous system. The response is directly related to the particular ear and canal within the inner ear that has the problem. It does not generally require investigations such as blood tests or scans. Occasionally, more specialized testing may be warranted where a clinician may wish to rule out less common causes of vertigo.

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Luckily, BPPV is usually straightforward to diagnose without requiring investigations such as blood tests or scans.

There are some situations, however, where a clinician will need to rule out other causes of vertigo; further investigation may be required in these cases.

What does BPPV feel like?

The “garden variety” of BPPV will feel like this:

  • Vertigo (often with nausea and sometimes with vomiting) is triggered by movement of the head. There may be a brief delay after moving the head, then the vertigo will last less than 2 minutes.

  • In most cases patients will see or feel the room spinning, though for some it may be a more vague dizziness or sense of being off-balance.

  • Symptoms come on suddenly. They are often first noticed turning in bed or when getting out of bed in the morning, though they can come on at any time.

  • Once an episode of vertigo has passed, it will stay settled until the head is moved.

  • There may also be vague symptoms such as tiredness, fogginess in the head, and blurry vision which may linger after the vertigo episode has passed.

  • There will not be any change to hearing, nor any other neurological symptoms.

What will my GP do if I have an episode?

When visiting your doctor, they may do a number of assessments. Among these, they may look in your ears, test your eyes and perhaps test your balance. They may perform several special tests to exclude any significant illness. On occasion, they may do positional testing, though this is not common. Often GP’s will make a diagnosis by your history and symptoms, though this is not the gold standard.

Should I be assessed with positional testing?

Yes, this is the gold standard! The current guidelines on assessing suspected BPPV were published in 2016 (ref 1). They recommend:

  • In-clinic diagnosis using the Hallpike-Dix and Supine Roll tests. These tests involve moving your head and, or body into particular positions and watching for specific eye movements (nystagmus) to occur. This will reproduce your symptoms if you have active BPPV and will often cause vertigo and may make you feel nauseated, but, it is important for accurate diagnosis and to guide treatment.

  • Clinicians should differentiate BPPV from other types of dizziness and vertigo.

At Bespoke Physiotherapy, we use special Frenzel goggles that record your eye movements during testing. This allows us to very accurately diagnose BPPV, as sometimes the eyes’ movements may be subtle and brief.

Generally, clinicians should not refer for radiographic imaging or vestibular function testing in these patients, unless there are additional signs/symptoms of other conditions which would require these investigations.

By being assessed and diagnosed quickly and accurately, patients can avoid unnecessary scans and reduce the burden on the healthcare system and enables patients to have prompt and effective treatment much sooner.

Vestibular physiotherapist can treat you very effectively for BPPV. With a skilled practitioner, 90% of BPPV cases will resolve after 1-3 treatment sessions (2). Vestibular physiotherapists are highly trained at assessing the vestibular system, neck, balance, and other related parts of the body and brain. They will test you to help rule out other conditions and can provide valuable input should you need to see a neurologist, otolaryngologist (ENT) or other specialist.

So, if you have been diagnosed with BPPV by your GP or specialist or if you have symptoms that sound like those of BPPV, seek out an excellent vestibular physiotherapist, like ours here at Bespoke Physiotherapy, and start feeling better, sooner.

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Once a diagnosis of BPPV is confirmed, a vestibular clinician can then commence treatment right away. In a skilled practitioner, 90% of BPPV cases will resolve after 3 or fewer sessions(2)!

References:

(1) Battacharyya N, et al. (2017). Clinical Practice Guidelines: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology-Head and Neck Surgery. 156(3_suppl): S1-S47. https://journals.sagepub.com/doi/10.1177/0194599816689667

(2) Parnes LS, et al. (2003). Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 169(7):681-693

Seated Stretches for Wheelchair Users

We all know that our bodies are designed to move. The way in which we go about our daily life will look different for everyone and depends on each person’s individual functional abilities. For those who spend the majority of their day in a wheelchair, regularly changing positions can be more challenging.

Wheelchairs allow individuals to have a greater capacity to get around independently, however spending a large amount of time in one position is not healthy for anybody.

Joints and muscles can become stiff and sore which may lead to less compliance within muscles and discomfort.

The many benefits of stretching for wheelchair users include:

  • Increased flexibility and joint range of motion

  • Improved circulation

  • Improved posture

  • Stress relief

  • Reduced muscle tension and spasticity

  • Increased energy levels

  • Improved sleep

We have collated our favourite stretches that can be easily performed in a wheelchair, so give them a go!

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  • Triceps Stretch

Reach one arm up towards the ceiling and place your hand behind your head by bending the elbow. Hold onto the elbow with the other hand and gently pull elbow sideways until a gentle stretch is felt in the shoulder or back of your upper arm. Hold for 30 seconds then repeat on the other arm.

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  • Shoulder Shrugs

Lift your shoulders up towards your ears and hold this for 5-8 seconds. Relax completely and allow your shoulders to drop down naturally. Repeat this several times. This exercise is good for relieving stiffness and tension in the shoulders and neck.

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  • Forward Flexion

Bend forward starting from the head to stretch from the neck through the lower back. Find a comfortable position and hold it for about 1-2 minutes. To sit up, put your hands on your thighs and push your upper body to an upright position.

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  • Seated Rotation

Turn your upper body to the right and then to the left while you continue breathing normally. This exercise will create a stretch in your back and sides. Repeat this a few times in each direction.

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  • Neck Stretch

Tilt your head to the left side while you allow your right shoulder to move downward. This exercise will create a stretch along the side of the neck. Hold for 30 seconds, then repeat on the other side.

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  • Side Stretch

Hold your left elbow with your right hand and gently pull your elbow behind your head until an easy stretch is felt. Gently lean sideways from your hips to stretch along the side of your body. Hold for 30 seconds then repeat on the other side.  

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  • Scapula Activation

Interlace your fingers behind your head, keeping your elbows straight out to the side. If this position is uncomfortable, just rest your hands on your thighs. Gently bring the shoulder blades towards each other. Hold this position for 10-15 seconds; you should be able to feel the muscles in the upper back working. Repeat 10 times.

  • Hip Stretch

Lift your knee toward your chest until a gentle stretch is felt. Hold the position until the stretch lessens, then stretch a little further until a mild, comfortable stretch is felt again. Repeat this on the other leg.

We always suggest that prior to starting an exercise program you make an appointment with one of our skilled Physiotherapist 9329 5551 so that they can guide you with a tailored exercises program to best suit you.

Resources:

https://enabled.in/wp/wheelchair-users-exercises-resources-and-guides/

How to master working from home

Working from home has probably become the new normal for a lot of us over the last few months. However, it is likely that you don’t have the same ergonomic set-up that you do at work. Spending many hours at a work station that is not well set-up can result in back and neck discomfort, eye strain, and headaches, as well as reducing your productivity and efficiency. 

Here are a few tips and tricks to make your home office set-up as comfortable and efficient as possible:

  • Chair height: Hips should be slightly higher than knees and feet placed flat on the floor to reduce strain on the low back. A kitchen chair can work well in the absence of a traditional office chair. Add a small lumbar pillow or roll up a towel to place in the small of the back if needed. If you have armrests, make sure they are set low enough that your shoulders aren’t scrunching up.

  • Screen: The top of the screen should be at or just below eye level and about an arm’s length away from your eyes to reduce neck and eye strain. If you only have a laptop, we recommend placing some books underneath it or getting a laptop stand to lift the height of the screen. 

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  • Desk or table height: Forearms should rest comfortably on the table, or arm rests of chair about parallel to the floor.

  • Movement: Set at timer for activity and stretching breaks every 30-60 minutes. Get up and walk or stretch. One of my favorite stretches that helps reverse the effects of prolonged desk work is an arm opening. Lie on your side with your arms straight in front of your shoulders, as seen in the photo on the left below. Breathe out as you lift your uppermost arm towards the ceiling and then allow the upper body to rotate so that the chest is turning towards the ceiling. Allow the head to follow the movement of the arm. Hold this position for a few breaths in and out, then bring the arm back to the start position.

If you are experiencing discomfort that does not resolve with these adjustments to your posture and set-up, do not hesitate to contact us. We may need to include some more specific and personalized recommendations or exercises to best help you.

 

Sitting is the new smoking

You may have heard the phrase “Sitting is the new smoking”, along with “Movement is Medicine” or “Motion is Lotion”. It’s becoming more and more clear that the sedentary behavior that has become so ingrained in modern society isn’t good for us. A big part of what we do is help our clients find ways to spend less time sitting stationary to allow for faster recovery from injury or surgery.

We have known for a long time that gentle movement and physical activity is helpful for conditions like back pain and osteoarthritis. However, research has also shown that independent of physical activity, sedentary behavior has been associated with cardiovascular disease, diabetes and some cancers (1). This means that going to the gym doesn’t fully negate the effects of sitting at your desk all day. See if you can add some incidental activity into your workday; maybe you could pace the corridor whilst on the phone or do 5 squats every time you go to the printer.

A question that we are commonly asked is “what is the perfect posture?” The short answer is there is none.

A question we commonly hear is, “what’s the perfect posture”. The short answer is that there is none. Ultimately, our bodies are designed to move. The most expensive and individualised ergonomic chairs and desks won’t stop you from feeling uncomfortable if you stay in the same position for hours at a time. Pain and discomfort is often a result of the subconscious brain reminding you to stretch your muscles and lubricate your joints. Try thinking about pain as a helpful reminder that your body needs to do something different.

If you have an office job or drive long distances, try this stretch to break up periods of sitting.

  1. de Rezende, L. F. M., Lopes, M. R., Rey-López, J. P., Matsudo, V. K. R., & do Carmo Luiz, O. (2014). Sedentary behavior and health outcomes: an overview of systematic reviews. PloS one, 9(8), e105620.

Can I return to running after injury?

One of the most common topics we are asked about is running – Can I run again? Is running bad for my recovery? Can running lead to other injuries?

Running is a great activity for cardiovascular fitness, strong bones and muscles, healthy joints and weight maintenance.

A common concern is that running will lead to ‘wear and tear’ of the joints. A recent review of 25 studies which included over 120,000 individuals found that only 3.5% of recreational runners developed hip or knee osteoarthritis, compared to 10.2% of non-runners and 13.3% of professional/elite runners (1). We think this is because running causes the joint structures to become more resilient to load over time.

Running has also been associated with increased strength and height of the intervertebral discs in your spine (2). Similarly, the spinal discs seem to become stronger when they are repeatedly exposed to the forces associated with running. 

It is important to discuss running with your surgeon/specialist and physiotherapist before returning. Most injuries and surgeries don’t preclude you from running, however a gradual exercise program is vital to condition your body for the forces of running and develop an efficient and safe technique. 

Studies of professional athletes have found that 88% of those who underwent lumbar microdiscectomy (a lower back surgery) (3) and 81% of those who had lumbar disc herniations (4) successfully returned to professional sport. Anecdotally, we’ve certainly found that non-athletes can return to running and sport safely too if they commit time and dedication to the rehabilitation process. 

Aspects of running technique have been closely associated with risk of common running injuries (5). Your program will include training for components of running such as the fast push off created by your calf muscles, efficient cadence (steps per minute), arm swing and foot contact area to minimise the load on your joints when you run. You have a very efficient set of shock absorbers in your body, you just need to learn how to use them! 

Once you have your rehabilitation plan in place, consider having a footwear expert help you find a great pair of runners. Then look for a relatively soft surface to run on initially, such as a dirt or gravel track or level grass. Princess Park and The Tan are some of our local favorites. 

Talk to us about starting the return to running process and we can set you on the right path. 

References

  • Alentorn-Geli, E., Samuelsson, K., Musahl, V., Green, C. L., Bhandari, M., & Karlsson, J. (2017). The association of recreational and competitive running with hip and knee osteoarthritis: a systematic review and meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 47(6), 373-390.

  • Belavý, D. L., Quittner, M. J., Ridgers, N., Ling, Y., Connell, D., & Rantalainen, T. (2017). Running exercise strengthens the intervertebral disc. Scientific Reports, 7, 45975.

  • Watkins IV, R. G., Williams, L. A., & Watkins III, R. G. (2003). Microscopic lumbar discectomy results for 60 cases in professional and Olympic athletes. The Spine Journal, 3(2), 100-105.

  • Hsu, W. K., McCarthy, K. J., Savage, J. W., Roberts, D. W., Roc, G. C., Micev, A. J., ... & Schafer, M. F. (2011). The Professional Athlete Spine Initiative: outcomes after lumbar disc herniation in 342 elite professional athletes. The Spine Journal, 11(3), 180-186. 

  • Bramah, C., Preece, S. J., Gill, N., & Herrington, L. (2018). Is there a pathological gait associated with common soft tissue running injuries?. The American Journal of Sports Medicine, 0363546518793657.



What is Pain?

Part 1: A simplified version of a complex process

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Think of the brain as being a computer. Each area of our body is represented in the cortex of the brain. Some areas, such as the hand and mouth have a larger representation than others, such as the shoulder or elbow.

‘Data’ from our body such as temperature, stretch, compression, sensation and joint position are filed and organised by their specific body region within the tissue of the brain. The brain can then compute what each part of the body is doing at any given time.

Once this 'data' has been received and processed the brain now has a picture of what that body part is doing. To further make sense of this information it communicates with other brain regions, to add context and analyse the bodies overall picture. For example; what is my current mood, emotional state, fatigue levels, prior experience of this body part and what can my memory centres associated with the current movement or task tell me?

The brains number one job is to keep you safe; maintain homeostasis. So the first priority is asking itself: does this position/movement/task pose me any threat right now?

If it considers the information threatening the brain creates a pain output back to the tissues and the person experiences pain. Importantly, pain sends us a signal that the body feels threatened, but pain does not equal damage.

Listen: "The brains role in pain" - A short audio file demonstrating pain as an output

Find some balance in your life!

Balance helps us stay upright against gravity and steady in a very complex world. Our amazing ability to balance is something we take for granted until something in this finely tuned system goes wrong.

We use three main systems for our balance:

1. Proprioception (sensors in our muscles and joints that tell us where our body parts are in space)

2. Vestibular system (our primary balance organ in our inner ear)

3. Vision (helps us keep our gaze on a point and helps us orientate us in our environment)

Information from these three systems is brought together and processed by our brain very quickly (mainly in an area called the Cerebellum) and then the appropriate reaction is sent to our muscles to keep us upright.

This happens very quickly and this information is constantly being updated. Its so incredibly fast that we don't even realise it is happening!

When things go wrong with one of these systems the other systems have to work harder. If you stand in a challenging position, on one leg for example, and you close your eyes (take away your vision) it is harder to balance. As a result, your muscles in your feet and and around your ankles work harder to help you balance and you will need to concentrate harder on sensing where upright is.

If you can’t feel one or both of your feet very well due to numbness or pins and needles, then your proprioception is decreased and other parts of your body have to compensate more.

The good news is that this balance system is one of the most adaptable systems in our body. If we practice balancing it will improve. The trick is to pitch it at the right level for you and to practice often.  Ask one of Bespokes Physiotherapist's if this is an are you would like to explore and improve.  Make it part of your day. Make it playful and fun. Mix it up and vary it.

As we like to say, get some balance play in your day!

Here are some ideas:

1.  Stand with one foot in front of the other while brushing your teeth (or on one leg if this is where you are up to). You have the sink and the other hand for safety if required.

2. Every time you walk down a particular section of corridor in your house (or at work) do it a different way.  You could try walking on your heels, the next time on your toes, or walk the ‘tight rope’, walk sideways, walk backwards (if safe to do so). Safety first!

3. Try to get a little bit of spring in your day. When was the last time you skipped? When was the last time you jumped or hopped? There are easier variations of these you can ask your physiotherapist about.

4. Throw a ball up and down while standing in a position that challenges you. Try following the ball with your eyes.

5. Try balancing on a wobbly surface (Balance Foam is great) while watching the first 5-10 minutes of a Television show. If standing is too difficult sit on a wobbly surface instead (ball or balance foam or balance disc).

6. Balance whilst waiting for someone, a tram, a train, the microwave timer, the photocopier etc…

7. If you have a standing desk at work check/read your emails standing on some balance foam or a balance disc (transportable, light, good cushioning). 

8. Dancing is amazing for your balance. Put on a song and dance like no one is watching. Or join a dance class.  You would be surprised what is out there. Dance for Parkinson’s Disease or Tap dancing for bone density are just two examples.

In the pictures below are some examples (thanks to my parents both 74 years old). Two different people, two different balance tasks pitched to their level.

My Dad is recovering from a stroke. Every time he walks along a particular section of path made of bricks tries to walk along a single line of bricks. He overbalances and steps off the bricks to the side occasionally, which is a great stepping balance reaction. He keeps trying, he is improving!

My Mum walks along the beach and for short 10 metre sections she tries skipping. She finds it difficult on the uneven ground but it's fun and the more she practices the better she gets! Mum also goes to tap dancing lessons for her bone density and balance once a week.

Have you ever watched a child play? They never just walk from A to B.  They step over the lines, walk along a curb, jump only in the dark grey squares of a tiling pattern, they walk along a line of bricks, or a wall. They do not even think of practicing their balance, it is just fun.

So..... never act your age, find some balance play in your day!

 

WE'D LOVE TO HEAR WHAT SORT OF BALANCE PLAY YOU'RE INCORPORATING INTO YOUR DAY!

 

Hydrotherapy for MS: Debunking the Heat Sensitivity Barrier

The hydrotherapy pool has proven itself to be a great environment for improving fitness, increasing muscle strength, improved mobility and walking, reducing fatigue, improved well-being and quality of life for people suffering from multiple sclerosis.

What is heat sensitivity in MS?

Increased body temperature for a multiple sclerosis sufferer leads to slowing of nerve conduction and therefore an increased fatigue, weakness and temporary worsening of old or onset of new symptoms; usually resolving within 24 hours.

Will the warm pool contribute to heat sensitivity?

A common misconception amongst MS patients is that a hydrotherapy pool will be detrimental to their function as a result of heat sensitivity. However, water is a better conductor of heat than air, so heat can quickly be carried away for improved temperature regulation during more intense exercise in the pool- more so than on land. Studies have shown no adverse effects for people with MS in pools with a temperature of 25-35°c.

Tips for Managing Heat Sensitivity

  • Exercise in a well-ventilated pool with a temperature of 25-35 degrees

  • Stay well hydrated

  • All exercise requires an adaptation period, so take regular short rest breaks

  • Everyone’s body is different: Try exercising in a few different pools/ different temperatures within the prescribed range and find which one suits your body best.

What do I do if my symptoms get worse following exercise in the pool?

If symptoms are worse for any more than 2 hours after a pool session, then the session is likely too challenging. Speak to your Neurological physiotherapist about how to modify your program.

Some comorbidities can affect your safety in the water, so make sure to discuss an appropriate hydrotherapy plan with us before commencing.

 

World MS Day 2018

World MS day is a wonderful international day that brings awareness to the disease and current research.  It's a day that makes us stop and think about the importance of a collaborative approach between the different healthcare professionals and our clients. 

At Bespoke we really enjoy working with the many members of our MS clients healthcare team, Neurologists, GP's, personal trainers, massage therapists, workplace employment consultants, just to name a few.  There are also a couple of organisations which we think do an amazing job raising awareness, conducting research and supporting people with MS.  I've attached the links just in case you're interested or are happy to give a few dollars to their worthy cause:

http://www.neuroscience.org.au/

https://www.msaustralia.org.au/stay-connected/world-ms-day-2018

https://www.ms.org.au/support-services/ms-connect.aspx

MS is  a complex disease requiring a comprehensive approach. Lets work together #bringinguscloser

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#bringinguscloser

Professor Claude Bernard, Internationally renowned MS researcher with Jane Costello